Sarah Hiddleston

The United Nations General Assembly Special Session has let go of a great chance to ensure gains in the fight against the pandemic.

MEMBERS AT last week's United Nations General Assembly Special Session (UNGASS) noted, a quarter of a century into the AIDS pandemic, that, "we are facing an unprecedented human catastrophe." However, they were unable to commit to concrete targets and funding to halt the disease's spread.

The 2006 declaration comes at a time of great opportunity when experts are tentatively pointing to the first slowdown in 25 years.

In contrast to the boldness of the specific time-bound commitments of the U.N. Declaration on HIV/AIDS 2001, the 2006 document reflects an unwillingness to admit to the realities of the pandemic. According to the civil society coalition monitoring the U.N. drafting process, the following concrete pledges are missing: comprehensive prevention strategies for vulnerable populations, targets for universal access to treatment by 2010, and timetabled funding for all AIDS prevention, treatment, care, and support programmes.

Vulnerable groups

Today, the groups most vulnerable to the pandemic include women and girls, youth, older people, men who have sex with men, drug users, sex workers, transgenders, people living in poverty, prisoners, migrant labourers, orphans, people in conflict and post-conflict situations, indigenous peoples, refugees and internally displaced persons, as well as HIV/AIDS outreach workers, and people living with HIV/AIDS.

Barring a late-stage recognition of the feminisation of the epidemic, these groups remain without frameworks addressing their specific needs, or targets through which real change can be made. Examples include provision of clean needles and condoms, substitution therapy for drug users, unstigmatised access to services and treatment, and prevention outreach programmes. Breakthrough negotiations on the final day of the U.N. session saw the ratification of the rights of women to protection and provision of health care and services by 2015. These exclude specifics on the rights of girls married in childhood (under 18).

This is largely owing to an unusual alliance of the American Christian Right and Muslim nations, including Pakistan, Iraq, and Egypt, which displayed precisely the prudishness about sex that has allowed AIDS to reach such proportions. Their outright rejection of groups such as men who have sex with men, sex workers, drug users, and transgenders may reinforce discrimination, cut them off from resources allocated to tackle HIV, and lead to increased infections.

Last year, the G8 group of wealthy nations pledged to achieve "as close as possible" to universal access to treatment by 2010. Today, over 40 million people are HIV positive; 10 million of them desperately need treatment.

Under pressure from the United States and others, African leaders allowed a progressive deal made in Abuja, Nigeria, in May to be sidelined at the U.N. It had endorsed ambitious targets towards universal access by 2010.

It included programmes designed to prevent transmission to newborns for 80 per cent of mothers, basic services for 80 per cent of orphans and vulnerable children, access to antiretroviral treatment for 80 per cent of those in need, access to voluntary testing and condoms for 80 per cent of target populations, and access to AIDS medicines for all those with tuberculosis.

No such commitments exist in the U.N. declaration. Instead, it uses broad-brush statements recognising the importance of universal access to prevention, treatment, care and support programmes, and drawing up targets by 2008. If the UNAIDS estimate for last year's death toll is taken as a parameter, 5.6 million people will have died in the intervening two years. "The continent that is most ravaged by AIDS has demonstrated a complete lack of leadership," said Omololu Faloubi of the African Civil Society Coalition.

U.S.-based groups such as the Global AIDS alliance have berated their government for "weakening language on HIV prevention, low-cost drugs, trade agreements and ... targets and funding for prevention and treatment."

Since 2001, the U.S. administration has preferred to commit most of its HIV spending via the President's Emergency Fund for AIDS Relief (PEPFAR), through which it can enforce abstinence-only programmes and forbid the use of cheap generic life-saving medicines that are not approved by the Federal Drugs Administration.

The adopted declaration estimated that $23 billion a year will be needed by 2010 to fund AIDS programmes. Despite the fact that this is nearly triple the $8.3 billion spent in 2005, U.N. members did not commit to a timetable for raising the funds.

The Global Fund to Fight AIDS, TB, and malaria set up in response to the 2001 declaration, is already facing a funding shortfall of over $90 million for this year (round 6) and next year over $1.2 billion for next year (round 7). "At this stage of the pandemic we expected government commitments to close the global funding gap," said Kieran Daly of the International Council of AIDS Service Organisations.

Until governments commit to funding, programmes cannot be properly constructed and implemented. As Richard Feachem, Executive Director of the Global Fund, told The Financial Times "without full funding, the G8 pledge is just [a] pie in the sky."

India's realities

The Indian delegation has rejected the findings of the UNAIDS report released last week, which estimated that there were 5.7 million people living with HIV/AIDS in the country. This represents an increase of 600,000 from 5.1 million in 2004. Union Health Minister Anbumani Ramadoss told Reuters that he totally disagreed with the UNAIDS estimate, preferring the in-country figure of 5.2 million. According to Reuters, UNAIDS has reached these conclusions by expanding the age population affected outside the 15-49 bracket, including 50,000 children.

The challenges for India's fight against the epidemic bear relation to the issues thrown up at the U.N. meeting. In 2005, the National AIDS control Organisation (NACO) reported a funding shortfall of $128 million in 2006 and $170 million in 2007.

NACO also reported these findings among its classified `most-at risk' groups: awareness among sex workers is low at a national level, except in Tamil Nadu, Maharastra, Andra Pradesh, Goa, and West Bengal; infection from drug use is driving the epidemic in the Northeast and increasingly elsewhere; migrant workers have been difficult to track; highly mobile men are reasonably aware of HIV but do not often take action; since homosexuality is illegal in India the number of men who have sex with men accessing services is very low.

India accounts for more than 70 per cent of all of Asia's treatment needs, but only seven per cent of infected people in India received antiretroviral treatment. Many of those in the high-risk groups find it difficult to access services because they are stigmatised in treatment centres and hospitals.

The 2006 declaration has done little to provide a funding outlook or targets upon which NACO will be able to base interventions for vulnerable populations and treatment rollout in the third stage of its programme. Activists fear continued stigmatisation, lack of treatment and resource provision and increased infection.

The 2006 declaration will not be seen as a milestone in the fight against HIV. At a potential turning point, it has not provided standards for national models. At best it rubber stamps the 2001 declaration and acknowledges the scale of the issue. At worst it has missed an unparalleled opportunity to ensure gains in the fight against the pandemic.